Journal of Pain & Palliative Care Pharmacotherapy. 2015;Early Online:1–3. Copyright © 2015 Informa Healthcare USA, Inc. ISSN: 1536-0288 print / 1536-0539 online DOI: 10.3109/15360288.2014.997851
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by University of California San Francisco on 03/15/15 For personal use only.
PATIENT EDUCATION AND SELF-ADVOCACY: QUESTIONS AND RESPONSES ON PAIN MANAGEMENT Edited by Yvette Col´on
Implications of Bariatric Surgery on Chronic Pain and Opioid Use Vittal R. Nagar and Pravardhan Birthi A B STRA CT Questions from patients about pain conditions, pain treatment, and responses from authors are presented to help educate patients and make them effective self-advocates. The topics addressed in this report are implications of bariatric surgery or weight loss surgery on chronic pain and opioid use, what to expect with regards to pain control, and the need to change opioid dose after bariatric surgery. KEYWORDS opioids, surgery, bariatric, pain, chronic, dosing
cisions at locations far from the point of interest. The most common laparoscopic procedure used for weight loss is laparoscopic banding surgery. In this, the surgeon places a band around the upper part of stomach to create a small pouch to hold food and the band limits the amount of food a person can eat by making them feel full after eating small amounts of food. This surgery is commonly performed among patients who are old, have lower presurgical Body Mass Index (BMI), and lower presence of co-occurring disease burden4. The BMI is a measure of relative weight based on an individual’s mass and height. In laparoscopic gastric bypass surgery, the surgeon will divide stomach into a small upper section called the pouch and a larger bottom section; later, a connection is made between pouch and part of small intestine. Patients who undergo this procedure have been shown to have less post-surgical pain, although they still require opioids for pain control.5 Obstructive sleep apnea (OSA), a breathing disorder characterized by pauses in breathing or instances of shallow or infrequent breathing during sleep due to obstruction of the upper airway, and other forms of sleep problems are common among weight loss surgical patients.6 In addition, psychiatric disorders are also frequently found among weight loss surgical patients. Studies in the US weight loss surgical population have shown that the rate of lifetime history
QUESTION FROM A PATIENT I have chronic osteoarthritis and used to take morphine for pain control. After my planned bariatric surgery, my surgeon said I may have to change the dose of morphine. Since you have been prescribing morphine to me, what is the effect on pain after surgery? How much should we have to go down on my morphine dose? I’m a 58-year-old male with a BMI of 60. I have history of anxiety and depression.
RESPONSE Bariatric or weight loss surgery has been used to treat obesity, as well as its associated conditions such as heart disease1 and chronic pain.2 In recent years, the majority of weight loss surgeries are performed through laparoscopic techniques.3 Laparoscopic technique is a modern surgical technique in which operations are performed by making small inVittal R. Nagar MD, is a Resident Physician and PhD Candidate in the Department of Physical Medicine and Rehabilitation, University of Kentucky, Lexington, Kentucky. Pravardhan Birthi, MD, is with the Pain Management Service, Saint Francis Medical Center, Grand Island, Nebraska. Address correspondence to: Vittal R. Nagar MD, Department of Physical Medicine and Rehabilitation, University of Kentucky, Lexington, KY. (Tel: 859257-4890; Fax: 859-323-1123; E-mail: [email protected])
1
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by University of California San Francisco on 03/15/15 For personal use only.
2
V. R. Nagar and P. Birthi
of psychiatric disorders ranges from 37 to 66%, and a prevalence of psychiatric disorders at the time of surgery ranges between 24 and 38%.7 Anxiety, past psychiatric hospitalization, eating disorder, age and sex are important determinants to predict postsurgical opioid requirement.8 Thus, patient characteristics influence postsurgical opioid use. These factors need to be considered when planning to optimize postsurgical pain control and chronic pain management. Studies have shown that weight loss surgery can improve osteoarthritis associated knee pain and function; and decrease back pain.9,10 However, effect of weight loss surgery on fibromyalgia or hip pain is less clear.2,11 As some pain syndromes are associated with obesity, it can be assumed that weight loss may be associated with better pain control. It is generally anticipated that weight loss surgery would result in reduced pain and reduced opioid use. However, studies have shown that there was an increase in postsurgical chronic opioid use irrespective of presurgery chronic pain and/or depression diagnoses.12 In one of the recent study done on a group of US weight loss surgery population, 8.1% of patients who used opioids intermittently the year before weight loss surgery used opioids chronically the year after surgery. Whereas, 1.3% patients who did not use opioids a year presurgery opioids after a year of surgery. In the same study, relative to the year before surgery, opioid use among chronic opioid users before surgery increased by 13% the first year after surgery and by 18% across 3 postsurgery years.12 The study also showed that, patients who were dispensed 60 to 119 days’ supply of opioids the presurgery year were 13.23 to 14.29 times more likely to use opioids chronically postsurgery than patients without opioid use presurgery.12 The explanation to the contrasting finding could be some patients likely had pain unresponsive to weight loss but potentially responsive to opioids.13 A study did not find any differential increase in opioid use after surgery in individuals who lost more than 50% BMI while comparing individuals who lost less than 50% BMI.12 So multiple factors contribute to increasing chronic opioid use over time. Obese individuals demonstrate more pain sensitivity and lower pain detection thresholds than nonobese. Furthermore, altered pain processing persists even after weight loss surgery.14 The factors which apply to general population and also to weight loss surgery population include long-term opioid use leading to tolerance. So patients need to take higher opioid doses to achieve pain control even after weight loss surgery.12 Among the postweight loss surgery population, many individuals using opioids chronically for noncancer pain continue to experience pain and activity
limitations. Effective pain management in the weight loss surgery population is challenging because nonselective nonsteroidal anti-inflammatory agents are avoided and acetaminophen is less successful in producing a desired result.15 So, clinicians have fewer medication options for weight loss surgery patient’s pain management. When opioids are used, careful management includes awareness of side effect, tolerance and dependence, and adherence to medication schedule along with close monitoring.16 Studies have shown that using laparoscopic banding surgery could decrease the likelihood of becoming a chronic opioid user postsurgery, which needs further research. This could be related to less invasive nature of the surgery, which is generally performed for older patients, with lower presurgical BMI and lower associated medical problems.4 In one of the study, younger male patients undergoing laparoscopic weight loss surgery, who have been previously hospitalized for psychiatric disorders used more opioids in the first 48 hours postsurgery.17 Another study showed that, 4.0% of patients who did not use opioids chronically prior to weight loss surgery became chronic users the year after surgery.18 In summary, obese patients who seek weight loss surgery with an expectation to ease chronic pain should be educated and cautioned about possible increase in pain sensitivity and increase in opioid use after weight loss surgery, so that better decisions can be made. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
REFERENCES [1] Adams TD, Davidson LE, Litwin SE, Kolotkin RL, LaMonte MJ, Pendleton RC, Strong MB, Vinik R, Wanner NA, Hopkins PN, Gress RE, Walker JM, Cloward TV, Nuttall RT, Hammoud A, Greenwood JL, Crosby RD, McKinlay R, Simper SC, Smith SC, Hunt SC. Health benefits of gastric bypass surgery after 6 years. JAMA. 2012;308(11):1122-31. [2] Hooper MM, Stellato TA, Hallowell PT, Seitz BA, Moskowitz RW Musculoskeletal findings in obese subjects before and after weight loss following bariatric surgery. Int J Obes (Lond).2007;31(1):114-20. [3] Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K. Bariatric surgery: A systematic review and meta-analysis. JAMA. 2004;292:1724-37. [4] Flum DR, Belle SH, King WC, Wahed AS, Berk P, Chapman W, Pories W, Courcoulas A, McCloskey C, Mitchell J, Patterson E, Pomp A, Staten MA, Yanovski SZ, Thirlby R, Wolfe B. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;361:445-54. [5] El Shobary H, Christou N, Backman S, Gvocdic B, Schricker T. Effect of laparoscopic versus open gastric bypass surgery on
Journal of Pain & Palliative Care Pharmacotherapy
Implications of Bariatric Surgery on Chronic Pain and Opioid Use
[6]
[7]
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by University of California San Francisco on 03/15/15 For personal use only.
[8]
[9]
[10]
[11]
[12]
C
postoperative pain and bowel function. Obes Surg. 2006;16:43742. Frey WC, Pilcher J. Obstructive sleep-related breathing disorders in patients evaluated for bariatric surgery. Obes Surg. 2003;13:676-83. Kalarchian MA, Marcus MD, Levine MD, Courcoulas AP, Pilkonis PA, Ringham RM, Soulakova JN, Weissfeld LA, Rofey DL. Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. Am J Psychiatry. 2007;164:328-34. Granot M, Ferber SG. The roles of pain catastrophizing and anxiety in the prediction of postoperative pain intensity: a prospective study. Clin J Pain. 2005;21:439-45. Josbeno DA, Jakicic JM, Hergenroeder A, Eid GM. Physical activity and physical function changes in obese individuals after gastric bypass surgery. Surg Obes Relat Dis. 2010;6(4):361-6. Khoueir P, Black MH, Crookes PF, Kaufman HS, Katkhouda N, Wang MY. Prospective assessment of axial back pain symptoms before and after bariatric weight reduction surgery. Spine J . 2009;9(6):454-63. Saber AA, Boros MJ, Mancl T, Elgamal MH, Song S, Wisadrattanapong T. The effect of laparoscopic Roux-en-Y gastric bypass on fibromyalgia. Obes Surg. 2008;18(6):652-5 Raebel MA, Newcomer SR, Reifler LM, Boudreau D, Elliott TE, DeBar L, Ahmed A, Pawloski PA, Fisher D, Donahoo WT, Bayliss EA. Chronic use of opioid medications before and after bariatric surgery. JAMA. 2013; 310(13):1369-76.
2015 Informa Healthcare USA, Inc.
3
[13] Finnerup NB, Sindrup SH, Jensen TS. The evidence for pharmacological treatment of neuropathic pain. Pain. 2010;150(3):573-81. [14] Dodet P, Perrot S, Auvergne L, Hajj A, Simoneau G, Decl`eves X, Poitou C, Oppert JM, Peoc’h K, Mouly S, Bergmann JF, Lloret-Linares C. Sensory impairment in obese patients? Sensitivity and pain detection thresholds for electrical stimulation after surgeryinduced weight loss, and comparison with a nonobese population. Clin J Pain. 2013;29(1):43-9. [15] Sasse KC, Ganser J, Kozar M, Watson RW, McGinley L, Lim D, Weede M, Smith CJ, Bovee V. Seven cases of gastric perforation in Roux-en-Y gastric bypass patients. Obes Surg. 2008;18(5):530-4. [16] Trescot AM, Helm S, Hansen H, Benyamin R, Glaser SE, Adlaka R, Patel S, Manchikanti L. Opioids in the management of chronic non-cancer pain. Pain Physician. 2008;11(2):S5-S62. [17] Weingarten TN, Sprung J, Flores A, Baena AM, Schroeder DR, Warner DO. Opioid requirements after laparoscopic bariatric surgery. Obes Surg. 2011;21(9):1407-12. [18] Raebel, MA, Newcomer SR, Bayliss EA, Boudreau D, DeBar L, Elliott TE, Ahmed AT, Pawloski PA, Fisher D, Toh S, Donahoo WT. Chronic opioid use emerging after bariatric surgery. Pharmacoepidem. Drug Saf. 2014;12:1247-57.
RECEIVED: 31 August 2014 ACCEPTED: 4 December 2014
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by University of California San Francisco on 03/15/15 For personal use only.
PATIENT EDUCATION AND SELF-ADVOCACY: QUESTIONS AND RESPONSES ON PAIN MANAGEMENT Edited by Yvette Col´on
Implications of Bariatric Surgery on Chronic Pain and Opioid Use Vittal R. Nagar and Pravardhan Birthi A B STRA CT Questions from patients about pain conditions, pain treatment, and responses from authors are presented to help educate patients and make them effective self-advocates. The topics addressed in this report are implications of bariatric surgery or weight loss surgery on chronic pain and opioid use, what to expect with regards to pain control, and the need to change opioid dose after bariatric surgery. KEYWORDS opioids, surgery, bariatric, pain, chronic, dosing
cisions at locations far from the point of interest. The most common laparoscopic procedure used for weight loss is laparoscopic banding surgery. In this, the surgeon places a band around the upper part of stomach to create a small pouch to hold food and the band limits the amount of food a person can eat by making them feel full after eating small amounts of food. This surgery is commonly performed among patients who are old, have lower presurgical Body Mass Index (BMI), and lower presence of co-occurring disease burden4. The BMI is a measure of relative weight based on an individual’s mass and height. In laparoscopic gastric bypass surgery, the surgeon will divide stomach into a small upper section called the pouch and a larger bottom section; later, a connection is made between pouch and part of small intestine. Patients who undergo this procedure have been shown to have less post-surgical pain, although they still require opioids for pain control.5 Obstructive sleep apnea (OSA), a breathing disorder characterized by pauses in breathing or instances of shallow or infrequent breathing during sleep due to obstruction of the upper airway, and other forms of sleep problems are common among weight loss surgical patients.6 In addition, psychiatric disorders are also frequently found among weight loss surgical patients. Studies in the US weight loss surgical population have shown that the rate of lifetime history
QUESTION FROM A PATIENT I have chronic osteoarthritis and used to take morphine for pain control. After my planned bariatric surgery, my surgeon said I may have to change the dose of morphine. Since you have been prescribing morphine to me, what is the effect on pain after surgery? How much should we have to go down on my morphine dose? I’m a 58-year-old male with a BMI of 60. I have history of anxiety and depression.
RESPONSE Bariatric or weight loss surgery has been used to treat obesity, as well as its associated conditions such as heart disease1 and chronic pain.2 In recent years, the majority of weight loss surgeries are performed through laparoscopic techniques.3 Laparoscopic technique is a modern surgical technique in which operations are performed by making small inVittal R. Nagar MD, is a Resident Physician and PhD Candidate in the Department of Physical Medicine and Rehabilitation, University of Kentucky, Lexington, Kentucky. Pravardhan Birthi, MD, is with the Pain Management Service, Saint Francis Medical Center, Grand Island, Nebraska. Address correspondence to: Vittal R. Nagar MD, Department of Physical Medicine and Rehabilitation, University of Kentucky, Lexington, KY. (Tel: 859257-4890; Fax: 859-323-1123; E-mail: [email protected])
1
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by University of California San Francisco on 03/15/15 For personal use only.
2
V. R. Nagar and P. Birthi
of psychiatric disorders ranges from 37 to 66%, and a prevalence of psychiatric disorders at the time of surgery ranges between 24 and 38%.7 Anxiety, past psychiatric hospitalization, eating disorder, age and sex are important determinants to predict postsurgical opioid requirement.8 Thus, patient characteristics influence postsurgical opioid use. These factors need to be considered when planning to optimize postsurgical pain control and chronic pain management. Studies have shown that weight loss surgery can improve osteoarthritis associated knee pain and function; and decrease back pain.9,10 However, effect of weight loss surgery on fibromyalgia or hip pain is less clear.2,11 As some pain syndromes are associated with obesity, it can be assumed that weight loss may be associated with better pain control. It is generally anticipated that weight loss surgery would result in reduced pain and reduced opioid use. However, studies have shown that there was an increase in postsurgical chronic opioid use irrespective of presurgery chronic pain and/or depression diagnoses.12 In one of the recent study done on a group of US weight loss surgery population, 8.1% of patients who used opioids intermittently the year before weight loss surgery used opioids chronically the year after surgery. Whereas, 1.3% patients who did not use opioids a year presurgery opioids after a year of surgery. In the same study, relative to the year before surgery, opioid use among chronic opioid users before surgery increased by 13% the first year after surgery and by 18% across 3 postsurgery years.12 The study also showed that, patients who were dispensed 60 to 119 days’ supply of opioids the presurgery year were 13.23 to 14.29 times more likely to use opioids chronically postsurgery than patients without opioid use presurgery.12 The explanation to the contrasting finding could be some patients likely had pain unresponsive to weight loss but potentially responsive to opioids.13 A study did not find any differential increase in opioid use after surgery in individuals who lost more than 50% BMI while comparing individuals who lost less than 50% BMI.12 So multiple factors contribute to increasing chronic opioid use over time. Obese individuals demonstrate more pain sensitivity and lower pain detection thresholds than nonobese. Furthermore, altered pain processing persists even after weight loss surgery.14 The factors which apply to general population and also to weight loss surgery population include long-term opioid use leading to tolerance. So patients need to take higher opioid doses to achieve pain control even after weight loss surgery.12 Among the postweight loss surgery population, many individuals using opioids chronically for noncancer pain continue to experience pain and activity
limitations. Effective pain management in the weight loss surgery population is challenging because nonselective nonsteroidal anti-inflammatory agents are avoided and acetaminophen is less successful in producing a desired result.15 So, clinicians have fewer medication options for weight loss surgery patient’s pain management. When opioids are used, careful management includes awareness of side effect, tolerance and dependence, and adherence to medication schedule along with close monitoring.16 Studies have shown that using laparoscopic banding surgery could decrease the likelihood of becoming a chronic opioid user postsurgery, which needs further research. This could be related to less invasive nature of the surgery, which is generally performed for older patients, with lower presurgical BMI and lower associated medical problems.4 In one of the study, younger male patients undergoing laparoscopic weight loss surgery, who have been previously hospitalized for psychiatric disorders used more opioids in the first 48 hours postsurgery.17 Another study showed that, 4.0% of patients who did not use opioids chronically prior to weight loss surgery became chronic users the year after surgery.18 In summary, obese patients who seek weight loss surgery with an expectation to ease chronic pain should be educated and cautioned about possible increase in pain sensitivity and increase in opioid use after weight loss surgery, so that better decisions can be made. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
REFERENCES [1] Adams TD, Davidson LE, Litwin SE, Kolotkin RL, LaMonte MJ, Pendleton RC, Strong MB, Vinik R, Wanner NA, Hopkins PN, Gress RE, Walker JM, Cloward TV, Nuttall RT, Hammoud A, Greenwood JL, Crosby RD, McKinlay R, Simper SC, Smith SC, Hunt SC. Health benefits of gastric bypass surgery after 6 years. JAMA. 2012;308(11):1122-31. [2] Hooper MM, Stellato TA, Hallowell PT, Seitz BA, Moskowitz RW Musculoskeletal findings in obese subjects before and after weight loss following bariatric surgery. Int J Obes (Lond).2007;31(1):114-20. [3] Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K. Bariatric surgery: A systematic review and meta-analysis. JAMA. 2004;292:1724-37. [4] Flum DR, Belle SH, King WC, Wahed AS, Berk P, Chapman W, Pories W, Courcoulas A, McCloskey C, Mitchell J, Patterson E, Pomp A, Staten MA, Yanovski SZ, Thirlby R, Wolfe B. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;361:445-54. [5] El Shobary H, Christou N, Backman S, Gvocdic B, Schricker T. Effect of laparoscopic versus open gastric bypass surgery on
Journal of Pain & Palliative Care Pharmacotherapy
Implications of Bariatric Surgery on Chronic Pain and Opioid Use
[6]
[7]
J Pain Palliat Care Pharmacother Downloaded from informahealthcare.com by University of California San Francisco on 03/15/15 For personal use only.
[8]
[9]
[10]
[11]
[12]
C
postoperative pain and bowel function. Obes Surg. 2006;16:43742. Frey WC, Pilcher J. Obstructive sleep-related breathing disorders in patients evaluated for bariatric surgery. Obes Surg. 2003;13:676-83. Kalarchian MA, Marcus MD, Levine MD, Courcoulas AP, Pilkonis PA, Ringham RM, Soulakova JN, Weissfeld LA, Rofey DL. Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. Am J Psychiatry. 2007;164:328-34. Granot M, Ferber SG. The roles of pain catastrophizing and anxiety in the prediction of postoperative pain intensity: a prospective study. Clin J Pain. 2005;21:439-45. Josbeno DA, Jakicic JM, Hergenroeder A, Eid GM. Physical activity and physical function changes in obese individuals after gastric bypass surgery. Surg Obes Relat Dis. 2010;6(4):361-6. Khoueir P, Black MH, Crookes PF, Kaufman HS, Katkhouda N, Wang MY. Prospective assessment of axial back pain symptoms before and after bariatric weight reduction surgery. Spine J . 2009;9(6):454-63. Saber AA, Boros MJ, Mancl T, Elgamal MH, Song S, Wisadrattanapong T. The effect of laparoscopic Roux-en-Y gastric bypass on fibromyalgia. Obes Surg. 2008;18(6):652-5 Raebel MA, Newcomer SR, Reifler LM, Boudreau D, Elliott TE, DeBar L, Ahmed A, Pawloski PA, Fisher D, Donahoo WT, Bayliss EA. Chronic use of opioid medications before and after bariatric surgery. JAMA. 2013; 310(13):1369-76.
2015 Informa Healthcare USA, Inc.
3
[13] Finnerup NB, Sindrup SH, Jensen TS. The evidence for pharmacological treatment of neuropathic pain. Pain. 2010;150(3):573-81. [14] Dodet P, Perrot S, Auvergne L, Hajj A, Simoneau G, Decl`eves X, Poitou C, Oppert JM, Peoc’h K, Mouly S, Bergmann JF, Lloret-Linares C. Sensory impairment in obese patients? Sensitivity and pain detection thresholds for electrical stimulation after surgeryinduced weight loss, and comparison with a nonobese population. Clin J Pain. 2013;29(1):43-9. [15] Sasse KC, Ganser J, Kozar M, Watson RW, McGinley L, Lim D, Weede M, Smith CJ, Bovee V. Seven cases of gastric perforation in Roux-en-Y gastric bypass patients. Obes Surg. 2008;18(5):530-4. [16] Trescot AM, Helm S, Hansen H, Benyamin R, Glaser SE, Adlaka R, Patel S, Manchikanti L. Opioids in the management of chronic non-cancer pain. Pain Physician. 2008;11(2):S5-S62. [17] Weingarten TN, Sprung J, Flores A, Baena AM, Schroeder DR, Warner DO. Opioid requirements after laparoscopic bariatric surgery. Obes Surg. 2011;21(9):1407-12. [18] Raebel, MA, Newcomer SR, Bayliss EA, Boudreau D, DeBar L, Elliott TE, Ahmed AT, Pawloski PA, Fisher D, Toh S, Donahoo WT. Chronic opioid use emerging after bariatric surgery. Pharmacoepidem. Drug Saf. 2014;12:1247-57.
RECEIVED: 31 August 2014 ACCEPTED: 4 December 2014
